Primary Care Coding Alert

Question: My provider documented that a patient has an overactive bladder. Does this mean the patient is incontinent? The notes don’t say that specifically. So, what’s the correct code?

New Jersey Subscriber

Answer: An overactive bladder does not on its own indicate that the patient is incontinent. This is a common misconception, which is dispelled by the clinical definitions of each condition.

Urinary incontinence: A common condition characterized by the loss of bladder control.

Overactive bladder: A condition characterized by the frequent and sudden urge to urinate that may be difficult to control. It can lead to incontinence.

From the descriptions of the conditions, you can see that overactive bladder commonly causes the patient to lose control of their bladder, but it doesn’t always. If the provider’s documentation does not specifically say the patient was incontinent, simply code the diagnosis as N32.81 (Overactive bladder).